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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University What is HAND? Manifests as HAND 10  Asymptomatic Neuropsychological Impairment (ANI)  Minor Neurocognitive Disorder (MND)  HIV-Associated Dementia (HAD) HAND highly prevalent among PLWH in developed countries 11-13  Up to 60% have some form (typically milder form)  HAD 1% - 10% Milder HAND associated with mortality and progression to HAD 14,15 Becoming more important as PLWH live longer

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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University HAND in South Africa Little known about prevalence and impact of HAND in South Africa  Yet, SA hardest hit by HIV with 5.5 million PLWH Recent study by Joska et al. (2010) 16  70% of younger adults with later stage HIV commencing ART had HAND (N=283)  25% HAD; 45% MND

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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University How is HAND detected/diagnosed? Neuropsychological tests that assess deficits in neurocognitive function  Do not detect disease, but rather pattern of impairment typical of the disease  Require stimulus books, forms, stopwatches, etc  Numerous tests and batteries available  Administration must be exact  Performance compared to normative sample Current gold-standard diagnosis requires multi-hour neuropsychological and neurological exam

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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University How is HAND detected/diagnosed? Screening for HAND not routine, 17,18 but could help:  Track and monitor  Make most appropriate referrals  Determine when to start ART Current screening tools just for HAD  HIV Dementia Scale (HDS) 19  International HIV Dementia Scale (IHDS) 20  Recent study used Montreal Cognitive Assessment (MoCA) 21 to screen for less severe HAND 22 Need for easy-to-use screening tools in South Africa:  Few neurologists and neuropsychologists, and other experts  Many undetected with HAND  Shift screening demands to lay personnel

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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University How is HAND Detected? From International HIV Dementia Scale

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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University Montreal Cognitive Assessment (MoCA): highest score = 30, ≤25 = mild impairment Multi-hour neuropsychological exam would include many more items like the MoCA, as well as timed tests of processing speed and motor function

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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University Detecting HAND in South Africa Neurocognitive screening challenging in South Africa  Few tools culturally validated with culturally appropriate norms Neuropsychological test performance negatively influenced by 23-26  Low education  Low literacy  Culture differences  Limited test-taking experience  All very common in South Africa International HIV-Dementia Scale and HIV-Dementia Scale validated for use in South Africa 27-29

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HIV CENTER for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University Conclusion MoCA has some potential  Some items discriminate  Some appear to be biased  Norms and cut-off score may not be appropriate Implications  Use “as is” will lead to inaccurate and inflated rates of HAND  Need to make item modifications, develop norms, and determine most accurate cut-off score Future research  Compare against gold standard  Compare expert to lay personnel administration

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